LATEST UPDATES TO THE CANADIAN VAP GUIDELINES. Tuesday, September Mardi 30 Septembre 2014

Transcription

1 LATEST UPDATES TO THE CANADIAN VAP GUIDELINES Tuesday, September Mardi 30 Septembre 2014

2 Your Hosts & Presenters Vos hôtes et présentateurs Bruce Harries, Collaborative Director Denny Laporta, MD, MSc, FRCPC; ICU Collaborative Chair Intensivist, Dept of Adult Critical Care; Jewish General Hospital; Faculty of Medicine, McGill University John Muscedere, MD, FRCPC Associate Professor, Department of Medicine & Critical Care Program, Queen s University; Research Director, Critical Care Program; Physician, Kingston General Hospital, Faculty Member Canadian ICU Collaborative Leanne Couves, Improvement Advisor Ardis Eliason, Technical Host 08/05/2014 2

3 Interacting in WebEx: Today s Tools Interagir dans Webex : outils à utiliser Have you used WebEx before? Avez-vous déjà utilisé WebEx? YES / OUI NO / NON Be prepared to use: - Pointer - Raise hand - CHAT - Text Tool writing on the slide - Shape Tools 08/05/2014 Soyez prêts à utiliser les outils : - le pointeur - lever la main - clavardage - Outil textuel pour «écrire sur la diapo» 3 - Outils de forme Select send to Type your message & click send

4 Who s Online? Qui est en ligne? POINTER 08/05/2014 4

5 POINTER What professions are represented? Quelles professions sont représentées? Nurse MD Infection Control Educator / Quality Improvement Professional Administrator / Senior Leader Respiratory Therapist Other Nutritionist 08/05/2014 5

6 Latest Updates to the Canadian VAP Guidelines Dr. John Muscedere

7 Canadian Clinical Practice Guidelines for Ventilator Associated Pneumonia (VAP) Dr. John Muscedere Queen s University

8 Learning Objectives 1. To understand the epidemiology of VAP. 2. To review the principles of diagnosis for VAP 3. To review Clinical Practice Guidelines for VAP: 1. Prevention 2. Diagnosis 3. Treatment

9 Epidemiology of VAP

10 Hospital-Acquired Pneumonia (HAP): Definitions Hospital Acquired Pneumonia: Arises 48 hours or more after hospital admission Is not incubating at the time of admission Ventilator-associated pneumonia (VAP): Arises hours or more after endotracheal intubation (up to hours after endotracheal intubation) Healthcare-associated pneumonia (HCAP): Arises within 90 days of admission to an acute care facility or residence in NH/LTCF. (American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171: )

11 Hospital Location & Relative Frequency of HAP & VAP HAP ICU Non-ICU HAP ICU HAP VAP HAP Non-ICU HAP ICU HAP VAP ICU HAP

12 Why the focus on VAP? Increased Mortality Depends on population Relative: 4-6% of ICU Mortality Absolute: 1 1.5% Mortality Adequacy and timeliness of antibiotic treatment Melsen et al, SR and MA of 52 Obs. studies, 17,000 patients RR 1.27 (1.15,1.39) Melsen et al, Crit Care Med, 2009 Baekert et al, AJRCCM, 2011

13 VAP: Impact Increases ICU Stay, Increases duration of Mechanical Ventilation and Increases duration of Hospital Stay Extra days in the hospital: 4-9 days Average extra days in ICU: 4.3 days

14 VAP: Canadian Healthcare Costs Cost per Case $11,450 Burden of Illness per year: Assuming 10.6 cases/1000 Vent days Excess Vent days 16,000 days (55 ICU beds) Excess Deaths Excess Cost 2 $46,000,000 1 Based on attributable mortality of 5.8% 2 Ontario cost cost methodology Muscedere et al, J Crit Care, 2008

15 Incidence Depends on how hard one looks Surveillance underestimates true incidence Reported rates vary: USA: NHSN 2-10 Cases/1000 vent days Ontario: 2.8 Cases/1000 vent days Multi-center Canadian study: 9 Cases/ 1000 vent days

16 Pathogenesis of HAP/VAP

17 Pathogenesis of VAP

18 Causative Pathogens

19 Classification of HAP & VAP: Risk Stratification Time from Hospitalization (days) Early-onset HAP Late-onset HAP Time from Intubation (days) Early-onset VAP Late-onset VAP (American Thoracic Society. Am J Respir Crit Care Med 2005;171: )

20 Pathogens to Consider When Treating HAP/VAP Early HAP/VAP Late HAP/VAP Timing Bacteriology Within five days of admission or mechanical ventilation S. pneumoniae H. influenzae Methicillin-sensitive S. aureus Susceptible gram-negative bacteria Five days or more after admission or mechanical ventilation P. aeruginosa Acinetobacter Methicillin-resistant S. aureus Other multi-resistant organisms Prognosis Less severe, little impact on outcome Mortality minimal Higher attributable mortality and morbidity (American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171: )

21 Diagnosis of VAP No reference standard for VAP Clinical features are non-specific and can be found in many other diseases CXRay: Neither sensitive nor specific Normal xray can help rule out VAP (? VAT) No pathognomic features of VAP

22 Diagnosis of VAP + Clinical + Chest X-Ray Microbiology Purulent secretions Increasing oxygen requirements Core temp > 38.0 o C WBC <3.5 or > 11.0 Pathogenic Bacteria New or Persistent Infiltrates

23 Obtaining Microbiological Sample for Diagnosis of VAP Invasive Bronchoscopy Quantitative Cultures Non-Invasive ETT Aspirate Non- Quantitative Cultures

24 Mortality of BAL vs ETA Meta-Analysis of All trials comparing ETA with BAL

25 VAT

26 VAC New and sustained respiratory deterioration ventilator-associated condition IVAC New respiratory deterioration with Infection-related concurrent infection ventilator-associated complication Possible pneumonia Probable pneumonia

27 An alternative paradigm for surveillance: Ventilator Associate Conditions (VAC) Definition: 2 days of stable or decreasing daily minimum PEEP or FiO2 followed by Rise in daily minimum PEEP 3 cm H 2 O sustained 2 days or Rise in daily minimum FiO2 20 points sustained 2 days Implemented in NHSN in January 2013

28 An alternative paradigm for surveillance: Infection Related Ventilator Associate Conditions (ivac) Definition: VAC associated with alterations in WBC (< to 4 or 12) or temperature (< 36 or 38 o C) within 2 days and Prescription of antibiotics continued 4 days

29 VAP Guideline Recommendations Prevention Diagnosis Treatment

30 Ann Intern Med. 2004;141: J Crit Care, 2008

31 VAP Guideline Recommendations: Prevention Use Oral Route for intubation May not apply to pts with: Maxillofacial trauma/surgery ENT surgery Difficult intubation

32 VAP Guideline Recommendations: Prevention Sub-glottic Secretion Drainage

33 Sub-glottic Secretion Drainage Muscedere et al, CCM 2011

34 VAP Guideline Recommendations: Prevention Subglottic Secretion Drainage Requirement for prolonged mechanical ventilation May not apply to pts with: Nasally intubation Tracheostomy tube Difficult endotracheal intubation

35 VAP Guideline Recommendations: Prevention Semi-recumbent positioning at 45 degree angle May not apply to pts with: Patient on vasopressors or undergoing resuscitation Spine unstable or not cleared Pelvic instability or fractures Prone position Intra aortic balloon pump Unable to raise HOB because of obesity Procedures (includes bathing)

36 VAP and Semi-recumbency: The evidence Outcome: The occurrence of VAP Patient population: Total of 409 patients studied Head of bed elevation achieved only measured in van Nieuwenhoven study

37 VAP Guideline Recommendations: Prevention Chlorhexidine Oral Antiseptic May not apply to pts with: Chlorhexidine Allergy Lack of access to patient s oral cavity

38 CHX decontamination compared with no prophylaxis on risk of VAP

39 VAP Guidelines: Diagnosis

40 Diagnostic Bronchoscopy NOT RECOMMENDED No improvement in clinical outcomes (mortality, length of stay, antibiotic use) compared to endotracheal aspirate May lead to delays in initiation of antibiotic therapy Requires expertise, time and personnel without added benefit

41 VAP Guideline Recommendations: Diagnosis Diagnosis of suspected VAP Endotracheal aspirates with nonquantitative culture May not apply to pts with: Immunocompromised patients at physician s discretion

42 VAP Diagnosis Clinical Suspicion of VAP New or persistent infiltrate on CXR plus 2 of the following: Purulent endotracheal secretions Increasing FiO2 requirements Elevated temperature (> 38.0) Increased WBC (>11.0) or decreased WBC (<3.5) Endotracheal aspirate Diagnosis of VAP Consider diagnostic bronchoscopy for immunosuppressed patients

43 VAP Guidelines: Treatment

44 Treatment of VAP Initial inadequate empiric therapy of VAP is associated with worse outcome Delays in therapy associated with worse outcome ATS Guidelines, 2005 Kuti, JCC 2009

45 Impact of adequacy of empiric therapy on outcome Adequate Inadequate p-value* (n=313) (n=37) Died within 14 days 33 (10.5%) 9 (24.3%) 0.01 Died within 28 days 51 (16.3%) 12 (32.4%) 0.02 Died in ICU 37 (11.8%) 13 (35.1%) Died in Hospital 61 (19.5%) 18 (48.7%) < Muscedere, JCC 2011

46 VAP Guideline Recommendations: Treatment Initiation of empiric treatment for VAP Start antibiotics at time of VAP suspicion (do not wait for culture results) May not apply to pts with: none

47 VAP Guideline Recommendations: Treatment Antibiotics for empiric treatment of VAP Single effective agent for each suspected organism May not apply to pts with: Patients known to be colonized or previously infected with Pseudomonas sp. or multidrug resistant organisms Immunocompromised patients

48 VAP Guideline Recommendations: Treatment Monotherapy vs. Combination Therapy: Mortality

49 VAP Guideline Recommendations: Treatment Choice of antibiotics for empiric treatment of VAP Based on local ICU resistance patterns and patient factors May not apply to pts with: none

50

51 VAP Guideline Recommendations: Treatment Discontinuation of empiric antibiotics for VAP If noninfectious etiology of infiltrates is found OR If signs and symptoms of active infection have resolved May not apply to pts with: none

52 VAP Guideline Recommendations: Treatment Choice of Antibiotic for Confirmed VAP A vs. B : No evidence to favor one agent over another Multiple non-inferiority trials (approx. 30 trials) MRSA pneumonia Linezolid vs. Glycopeptides (Vancomycin)

53 MRSA VAP Pneumonia Clinical cure rate In the three studies Mortality at different time points reported No effect on mortality was reported

54 VAP Guideline Recommendations: Treatment Duration of antibiotic treatment for confirmed VAP Maximum of 8 days in patients in whom initial empiric therapy was appropriate May not apply to pts with: Immunocompromised patients

55 TREATMENT OF VAP Empiric Therapy Start empiric antibiotics at the time of clinical suspicion of VAP Antibiotic Selection Choose antibiotic on the basis of the microbiology and resistance patterns in the ICU Choose one effective antibiotic active against each potential pathogen Antibiotic Management Reassess each antibiotic daily based on culture results, and patient s signs and symptoms Duration of Antibiotic Therapy Stop empiric antibiotics for suspected VAP if another reason for patient s signs & symptoms found Stop antibiotics for confirmed VAP after 8 days of therapy

56 Thank You Questions?

57 QUESTIONS? RAISE YOUR HAND / LEVEZ LA MAIN OR/OU CHAT TO ALL PARTICIPANTS

58 Taking the Pulse Poll 08/05/

59 Instructions to download certificate

60 Canadian ICU Collaborative Faculty Paule Bernier, P.Dt., Msc, Présidente, Ordre professionnel des diététistes du Québec; Sir MB David Jewish General Hospital (McGill University), Montreal Paul Boiteau MD, Department Head, Critical Care Medicine, Alberta Health Services; Professor of Medicine, University of Calgary Mike Cass, BSc, RN, MScN, Advanced Practice Nurse, Trillium Health Centre Leanne Couves, Improvement Advisor, Improvement Associates Ltd. Carla Williams, Patient Safety Improvement Lead, CPSI Bruce Harries, Collaborative Director, Improvement Associates Ltd. Denny Laporta MD, Intensivist, Department of Adult Critical Care, Jewish General Hospital; Faculty of Medicine, McGill University Claudio Martin MD,Intensivist, London Health Sciences Centre, Critical Care Trauma Centre; Professor of Medicine and Physiology, University of Western Ontario; Chair/Chief of Critical Care Western Cathy Mawdsley, RN, MScN, CNCC; Clinical Nurse Specialist Critical Care, London Health Sciences Centre; John Muscedere MD, Assistant Professor of Medicine, Queens University; Intensivist, Kingston General Hospital Yoanna Skrobik MD, Intensivist, Hôpital Maisonneuve Rosemont, Montréal; Expert Panel for the new Pain, Sedation and Delirium Guidelines, Society of Critical Care Medline (SCCM) 08/05/

61 Reminders Rappels Call is recorded Slides and links to recordings will be available on Safer Healthcare Now! Communities of Practice Additional resources are available on the SHN Website and Communities of Practice L'appel est enregistré Les diapositives et liens vers les enregistrements seront disponibles sur Des soins de santé plus sécuritaires maintenant! Communautés de pratique Des ressources supplémentaires sont disponibles sur le site Web SSPSM et Communautés de Pratique 08/05/

62 THANK YOU MERCI

63 This National Call is hosted by: Supported by: 08/05/